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  Herzing University Online   (Acct #7485)

  Case ID #: 1756-20180731-004   (Status: Approved)

Date of Service: 7/31/2018 

Student Information - Tennant, Angela

Semester:

Spring

Course:

NU 609 Advanced Health Assessment

Preceptor:

FLORES, MAY DR

Clinical Site:

FLORES AND FLORES ASSOCIATES

Setting Type:

Rural visit -

Patient Demographics

Age:

73 years

Race:

White, Non Hispanic

Gender:

Male

Insurance:

Private insurance

Referral:

Other

Clinical Information

Time with Patient:

15 minutes

Consult with Preceptor:

Type of Decision-Making:

Moderate complexity

Student Participation:

Shared (50-50)

Reason for Visit:

Follow-up (Consult)

Chief Complaint:

Follow up Exam.Had Blood Work done.

Encounter #:

No response

Type of HP:

Problem Focused

Social Problems Addressed:

Safety Prevention Education/Language Nutrition/Exercise  

Procedures/Skills (Observed/Assisted/Performed)

General Skills - Calculate BMI (Perf) General Skills - Ear exam (Perf) General Skills - Measurement of height (Perf) General Skills - Visual exam (Perf) General Skills - Weight (Perf)

ICD-10 Diagnosis Codes

#1 - 

K21.9 - GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS

#2 - 

Z72.0 - TOBACCO USE

#3 - 

110 is not a valid ICD code.

#4 - 

E11.40 - TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSP

#5 - 

E78.2 - MIXED HYPERLIPIDEMIA

#6 - 

M 54.5 is not a valid ICD code.

#7 - 

D50.9 - IRON DEFICIENCY ANEMIA, UNSPECIFIED

#8 - 

N39.42 - INCONTINENCE WITHOUT SENSORY AWARENESS

CPT Billing Codes

Medications

# OTC Drugs taken regularly:

3

# Prescriptions currently prescribed:

0

# New/Refilled Prescriptions This Visit:

0

Types of New/Refilled Prescriptions This Visit:  

Adherence Issues with Medications:  

Other Questions About This Case

Age Range:

85 years and older

Clinical Setting:

Primary Care

Patient Type:

History of Patient Illness (HPI):

type 2 Dm,GERD,HTN

Patient Education:

Smoking, Quitting

Patients Primary Language:

English

Time spent performing family assessment:

15 minutes

Other:

Alcohol use or abuse disorder:

Breast exam:

Cervical exam:

Diabetic consultation:

Did you chart on patient record?:

Yes

Discussed management with preceptor:

Domestic violence assessed:

History of tobacco use:

Yes

Handled visit independently:

Yes

Preceptor present during visit:

Yes

Lab review:

Yes

Newborn assessment:

Early postpartum visit

Mental health referral:

Contraception visit:

Clinical Notes

Subjective CC: Patient present for follow up exam.. HPI: Patient is a 73 year old here for a 4 month follow up exam. Patient had his bloodwork done and UA C & S which showed 1000cfu/ml ( not enough treat) He said that the had his bladder and renal scan done here. PMH: Problem List: Type 2 Diabetes Mellitus, Essential Hypertension, Gastroesophageal reflux disease, Essential Hypertension Health Maintenance: EKG Declined Flu Shot, Pneumonia, shingles vaccine- this as of 10/6/2015 Living Will- 2012 pg 9 of Archived Records. Medical Problems : Non Insulin Dependent Diabetes, Neuropathy, Diabetic, Hypertension, Gastroesophageal Reflux Disease Surgical Hx: No Past History of Procedure Hospitalizations: None Reviewed, No changes. ROS : Const: Denies constitutional symptoms Eyes: Denies eye symptoms ENMT :Denies ear symptoms. Denies nasal and sinus symptoms. Denies mouth or throat symptoms CV : Denies cardiovascular symptoms Resp : Denies respiratory symptoms GI : Denies gastrointestinal symptoms GU : Denies urinary symptoms Musculo: Denies musculoskeletal symptoms Skin: Denies skin, hair and nail symptoms Neuro : Denies neurologic symptoms Psych : Denies psychological symptoms Endocrine: Denies endocrine symptoms Hema/Lymph: Denies hematologic symptoms Allergy/ Immuno: Denies allergic/immunologic symptoms Meds Prior to Visit: Lisinopril 20 mg 1 every day Omeprazole 20 mg take one capsule by mouth daily Welchol 625 mg one pill three times a day BP Pen Needle Short 31 GX5/16 " use as directed. Aspirin Ec 81 mg 1 po qd BP pen Needle/ Short/Ultrafine/ 31GX5/16" 31G X 8mm use as directed Metformin HCL 1000 mg take 1 tablet by mouth twice a day Tamsulosin HCL 0.4 mg 1 by mouth every day Keflex 500 mg 1 by mouth twice a day Gabapentin 600 mg 1 three times a day. Lidocaine HCL 4% apply to affected area tid Januvia 100 mg 1 by mouth every day Enalapril Maleate 10 mg take 1 tablet daily Levemir Flex touch 100 Unit/ML inject 33 units every day Tamsulosin HCL 0.4 mg take by mouth once a day. Allergies : Baclofen FH: Cancer-Brother- (deceased) Reviewed No changes SH: Marital: Legal Status: Married. Lives With: Spouse. Occupation: Retired Personal Habits: Smoking: Patient is a current smoker, smokes every day- Patient was advised the risk of smoking such as cancer, COPD and premature death. Alcohol : Denies alcohol use Drug Abuse: Never used drugs. Daily Caffeine: Consumes on average 1 cup of regular coffee per day, Consumes on average of 48 oz of soda per day. Sexual Hx : Contraceptive: Current methods include abstinence Reviewed, No changes Date : 07/ 31/2018 Was the patient queried about smoking behavior? Yes Does the patient current smoke? Smoking: Patient is a current smoker, smokes every day- Patient was advised of the risk of smoking such as cancer, COPD and premature death. Was the patient counseled about smoking cessation? Yes. Objective: Ht: 70.25" 5'10.25" Wt: 159 lb oz. Wt Prior 65 lb 2 oz as of 06/18/18 Wt.Dif: -6lb-2 Ooz. BMI : 22.6 BSA : 1.90 BP:144/82 Resp: 18 Pulse: 96 T:97.5 Pain Level: 8 O2SatR:99 Exam: Const: Appears well developed and well nourished. No signs of acute distress present. Head/Face: Normal to inspection Eyes : EOMI both eyes. Conjunctivae clear. PERRL ENMT : External ears WNL. External canals are clear and dry. Tympanic membranes are intact. Nasal mucosa is clear. Oropharynx: Appears normal. Posterior pharynx is normal Neck: Palpation reveals suppleness. Thyroid is normal to palpation. Resp : Respiration rate is normal. Chest expansion is symmetrical. Lungs are clear bilaterally. CV : Rate is regular. Rhythm is regular.S1 is normal.S2 is normal. No heart murmur appreciated. Pedal pulses palpable Abdomen : Positive bowel sounds. Abdomen is soft, nontender, and nondistended. Musculo : Walks with normal age for gait. Upper Extremities: Normal to inspection. Lower Extremities : Normal to inspection Skin : Skin is warm and dry. Assessment # 1: k21.9 Gastro esophageal reflux disease without esophagitis Care Plan : Comments. : Patient sign his Living Will Reviewed Medication Reviewed Poly Pharmacy Assessment # 2 : Z72.0 Tobacco Use Care Plan : Comments : Smokes half a pack a day Declines Pneumonia Shot Declines Bone Density Scan He will think about Abnormal Aortic Aneurysm Screening next next OV. Advised patient to quit smoking. Discussed with patient the risk of tobacco use including lung and Cardiovascular disease, as well as negative outcomes including stroke, heart attack and cancer, respiratory failure, oxygen dependence. Encouraged cessation and offered assistance. Pat. Edu : Smoking, Quitting Assessment # 3 :110 Essential Hypertension Care Plan : Comments : Current BP 144/82 Pt reports BP range 140-80-90 Recheck BP 130/80 Advised to bring BP machine for comparison Advised to start low salt diet. Continue current med regimen Assessment # 4 : E11.40 Type 2 Diabetes Mellitus with diabetic neuropathy, Unspecified Care Plan : Comments : Pt reports no s/ s hypo/hyperglycemia Discussed s/s hypoglycemia BS range: 940-110 Assessment # 5 : E78.2 Mixed Hyperlipidemia Care Plan : Comments :Patient was advised low cholesterol, low triglyceride diet. Assessment # 6 : M54.5 Low Back Pain Care Plan : Assessment # 7 : D50.9 Iron deficiency anemia, unspecified Care Plan : Comments : Discussed lab results Results reflect Iron deficiency anemia Patient denies N/V/ D/, denies blood in stool/sputum. Recommended colonoscopy-SWGI consult Repeat labs x2 weeks to r/o acute, active bleeding Lab Orders : CBC Comp Metabolic Panel Occult Blood # 3 Stool Order : Colonoscopy Follow Up : 2 weeks Referral to SWGI for Anemia Referral to Dr. Ryan, urology for incontinence Assessment # 8 : N39.42 Incontinence without sensory awareness Care Plan : Comments : Pt states Inability to hold urine Pt referred to Urology- Dr. Ryan